Healthcare Provider Details

I. General information

NPI: 1245235134
Provider Name (Legal Business Name): WILLIE S CHAO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34800 BOB WILSON DR
SAN DIEGO CA
92134-1098
US

IV. Provider business mailing address

11228 LAURELCREST DR
SAN DIEGO CA
92130-6978
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-8600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number45557
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: